Crossroads LTSR
1100 South Pittsburgh Street
Crossroads
Connellsville,
PA 15424 LTSR
337 Tippecanoe Road – Smock Pa, 15480
Phone: 724-677-4445 Fax: 724-677-2379
LTSR CRITERIA CHECKLIST
(PLEASE PRINT LEGIBLY)
Consumer’s Name: _________________________________ Date: ____________
Person Completing Referral: _________________________ Agency: __________
Phone: ___________________ Ext: ___________ Email: ____________________
18 years or older
Psychiatric Diagnosis
Psychiatric Evaluation Attached
Yes
No, explain_______________________________
Medically Stable (vital signs stable, lab findings within normal limits, no complications due to
coexisting medical problems, does not require intensive medical interventions/monitoring)
Out of Seclusion or restraint for a minimum of 30 days
Yes
No, explain_________________________________________________________
Ability to provide self-care
Ability to ambulate stairs
Physical examination within 6 months
Physical Evaluation Attached
Yes
No, explain__________________________________
Current PPD (TB Test) - Results Attached
Current MRSA Status - Results Attached
Current Commitment Status
Commitment Attached
Yes
No, explain_______________________
No, explain________________________
201
304
305
306
No, explain_______________________________________
Yes
Physician Certification
Certification Attached
Yes
Yes
Certification that individual does not require hospitalization or a level
of care more restrictive than LTSR. (Will not admit without signature)
No
Social History
Social History Attached
Yes
No, explain______________________________________
Admit Note and 10 Days Most Recent Progress Notes
Progress Notes Attached
Yes
No, explain_____________________________________
Does Individual Have Advance Directive
If yes, Advance Directive Attached
2 Weeks of Medication Supply
Yes
Yes
No
No, explain_____________________________
Due to complex insurance issues we request 2 weeks of medication
to accompany the individual upon admission to LTSR.
Medication List
Medication Attached
Yes
No, explain________________________________________
Page 1 of 5
Updated: 05/01/10
Demographic Information
Consumer’s Name: _________________________________ Gender:
Male
Female
Social Security Number: ___________________ Date of Birth: ___________ Age: ____
Address _______________________________________________________________
State____ ZIP________ Phone _________
Education:
Grade School
Employment:
FT
PT
HS Diploma/GED
Student
Trade School
College
Masters
Other: _______________________
Other: ________ Location: ________________________________________
Marital Status: Single Never Married Married Divorced Separated Widowed Significant other:
Spouse/Significant Other Name: _______________________________ Phone: ____________
Living Information:
Homeless
Own Apartment/House
Supervised Living
Spouse/Significant Other
Children:
Yes
No Number under 18yrs: __________
If no, does client have access/visitation?
Yes
No
Personal Care Home
Number over 18yrs: _________
Parents
Custody
Yes
No
Emergency Contact: _______________________________ Contact Phone: __________
Relationship to Emergency Contact: __________________________
Financial and Insurance Information
SSI/SSDI:
Yes
Public Assistance:
No
Application Made; date: ___________ Monthly Amt $____________
Yes
No
Application made; date: __________ Monthly Amt $_________
Other Income: ________________________________________ Monthly Amt $_________
Representative Payee:
Yes
No
Application made; date: __________________
Payee Name: ________________________________ Payee Phone: _____________
Medicare Benefits:
Yes
No
Application made; date: ________
Medicaid Benefits:
Yes
No
Application made; date: ________
Veterans Admin Benefits:
Yes
Application made; date: ________
Primary Insurance Provider _______________ID #______________Policy #_________
Secondary Insurance Provider _______________ID #______________Policy #_______
Other Insurance Provider _________________ID #______________Policy #_________
Page 2 of 5
Updated: 05/01/10
Psychiatric Information
Current Admission Date: __________ Court Order on Admit:
201
302
304/305
Previous Admit Date: _________ Duration Previous Admit: _______________days/months
Number of Hospitalizations Past Year: _________
Number of Hospitalizations Life Time: _________
Restraint used this admission
Seclusion used this admission
Yes
Yes
No
Dates: _____________________________
No Dates: ______________________________
Reason for this Admission to Facility: ________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Summary of Issues, Behavior, and Treatment Interventions while at your facility:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Psychiatric Diagnosis
Axis I: _________________________________________________________________
Secondary: ______________________________________________________________
Axis II: ________________________________________________________________
Secondary: ______________________________________________________________
Axis III: _______________________________________________________________
Secondary: ______________________________________________________________
Axis IV: ________________________________________________________________
Secondary: ______________________________________________________________
Axis V: Admit: _______________
Current: __________________
Primary Psychiatrist: ___________________ Agency: ______________Phone: _______
Case Management (ICM):
Yes
No
Referral Made; date; __________________________
ICM Agency _______________________ Case Manager Name: ____________________
Page 3 of 5
Updated: 05/01/10
Substance Abuse Information
Substance Abuse prior to this hospitalization:
None
Cocaine
Crack
Alcohol
Marijuana
PCP
Heroin/Opiates
Amphetamines
Benzodiazepines
Other: ______________
Other: _____________
Frequency: Not in last month 1-3x in last month 1-2x per week 3-6x per week Daily Unknown
IV Drug
History of substance abuse:
Heroin/Opiates
Frequency:
None
Cocaine
Crack
Alcohol
Marijuana
PCP
IV Drug
Amphetamines
Benzodiazepines
Other: ______________
Other: _____________
Not in last month
1-3x in last month 1-2x per week
3-6x per week
Daily
Unknown
Drug screen completed at admission:
Yes
No Results: __________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Drug/Alcohol Rehab Facility:
Date(s):
Outcome:
________________________
_________
_________________________
________________________
_________
_________________________
Current Medical Information
Current Medication List Attached
Yes
No
Primary Physician: ___________________ Specialty: ______________Phone: _______
Other Physician: _____________________Specialty: ______________Phone: _______
Other Physician: _____________________ Specialty: ______________Phone: _______
Check All That Apply
AIDS
Anemia
Angina
Amputation
Asthma
Bleeding Diathesis
Blindness
Bone Disease
Cancer
CHF(congestive heart failure)
Colostomy
Coronary Artery Disease
COPD
CVA (stroke)
Cystostomy
Deafness
Dementia
Dermatitis Condition
Diabetes
insulin-dependent
Dialysis
GI Condition
GU Condition
Hepatic Disease
Hepatitis
HIV+
Head trauma (TBI)
Hypertension
Incontinence
Nighttime
Regularly
Daytime
Intermittent
Metabolic Dysfunction
Paraplegia
Paralysis
Pancreatitis
Renal disease
Rheum Disorder
Seizure History
Thyroid Disorder
Tracheotomy
Other:_______________
Other:_______________
Other:_______________
Other:_______________
ALLERGIES
Allergy:______________
Allergy:______________
Allergy:______________
Allergy:______________
Comments: _____________________________________________________________
______________________________________________________________________
Page 4 of 5
Updated: 05/01/10
TB Clearance: PPD Completed:
YES NO Evidence of Active TB:
YES NO
PPD results: _______ Date Planted: __________ Date Read: ____________
If positive, was X-ray done?
Yes
No X-ray Result: ______________
Current Height_____ Weight_____ Blood Pressure__________ Temperature_______
Individual Smoke:
Yes
No Packs per Day_____ How often____________
Tobacco Use:
Yes
No How often________________
Current Legal Status
Legal Status:
None
Probation
Parole
Incarceration
Warrants
Fines
Pending Charges
Probation/Parole Contact: _____________________________ Phone: ______________
Attorney’s Name:_____________________________________ Phone: _____________
Reason for Arrest: _______________________________________________________
Legal HX: ______________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Physician Certification Statement
Statement of Physician Certification
I, __________________________ am certifying that, the least restrictive and most
appropriate placement for ___________________________ is within a Long-Term
Structured Residential Facility (LTSR). I do hereby certify that the consumer is not in
need of acute psychiatric hospitalization, nursing facility care, or a level of care more
restrictive than a Long-Term Structured Residential Facility at this time.
Physician’s Signature
Date
Page 5 of 5
Updated:
05/01/10
revised 01/11/2013